Healthcare Provider Details

I. General information

NPI: 1699196386
Provider Name (Legal Business Name): BEBREH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MAIN ST
NANUET NY
10954-2800
US

IV. Provider business mailing address

121 MAIN ST
NANUET NY
10954-2800
US

V. Phone/Fax

Practice location:
  • Phone: 845-659-9368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number962778021
License Number StateNY

VIII. Authorized Official

Name: MRS. SULLYTE ELIE
Title or Position: OWNER
Credential:
Phone: 845-659-9368